Katie Allan's parents assist report into deaths in Scottish state care

Harrowing details obtained from Fatal Accident Inquiry reports include a case of one young man who was so distressed he called 999 from his cell during a mental health crisis.

Rather than carrying out a welfare check on him, prison officers confiscated his phone and he died by suicide the following evening.

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Researchers said the loss of life is largely going "unnoticed" and affect families "with the least power" and called for a human rights-based approach to be used in investigating the deaths.

It is the first time the Scottish Centre for Crime and Justice Research has collated figures for deaths in forms of state custody or control other than prisons.

The research, which is the first of its kind to be carried out in Scotland, found 144 people died while detained under the Mental Health Act, 39 died after having contact with the police, and 38 died in prison between September 2022 and October 2023.

A further 14 looked after children died during the same period, four people died in detention centres for migrants or in housing for asylum seekers, and three people with learning disabilities and autism died in hospital, while a further two died in police custody.

The report found deaths are on the rise in all of these groups other than in people with learning disabilities and autistic people.

In particular, the death rate in prison in 2021-23 was 618 per 100,000 compared to 242 in 2008-10 and in the past 10 years there were 50 deaths from drugs and 99 suicides in prison.

The rate of suicides in prison in Scotland is higher than in England, Wales, Australia and Europe.

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Sarah Armstrong, Professor of Criminology at the University of Glasgow, and co-author of the report Nothing to see here? Deaths in Scottish Custody 2023, said: "For the first time we are able to see the number of deaths across a range of settings for which the state has responsibility.

"Every week just in Scotland four people die, deaths that largely go unnoticed, and by far happen to and affect families with the least power.

"Each death is a tragedy but what makes it a public concern is the responsibility of the state for people’s care.

"Given this, one would expect robust and public methods of investigation.

"Sadly, this does not seem to be the case for most deaths."

Linda and Stuart Allen also gave input to the report. The couple became prison reform campaigners following the death of their daughter Katie in Polmont where she had been sent in March 2018 for a drink-driving offence in which a teenage boy had been injured.

Katie died by suicide in June 2018 and an FAI is currently investigating the circumstances around her death.

The research team also investigated 22 Fatal Accident Inquiries (FAIs), which are mandatory for people who have died in custody.

Twenty involved a death in prison, one in police custody and another in migration detention.

They found more than three-quarters of FAIs took longer than two years to complete and a third took more than three years.

More than 90% of inquiries concluded with neither a precaution nor a system defect, which is consistent with previous years’ findings.

Researcher and co-author Betsy Barkas said: “By looking at these specific FAIs we have learned harrowing details of the final days and hours of prisoners including young man who resorted to calling 999 from his cell because he was having a mental health crisis.

"Emergency services then tried to contact prison staff to carry out a welfare check, but no one picked up for one hour and 20 minutes.

"Even after speaking to emergency services prison staff didn’t carry out the welfare check, but confiscated his phone.

"The sheriff who presided over the Fatal Accident Inquiry, concluded the care provided to this prisoner was ‘competent and compassionate’ and that his death was unavoidable.

"No findings or recommendations means there were no lessons to be learned, or to put it simply, ‘there’s nothing to see here.’"

The report was published as the head of the Scottish Prison Service Teresa Medhurst told the BBC’s Disclosure programme that prisons have now reached a “tipping point” and that the system “cannot take anymore.”

She warned that pressures could result in the use of emergency powers to release inmates early. Scottish Liberal Democrat justice spokesperson Liam McArthur MSP said: "These findings make for disturbing reading.

"This is a startling number of deaths in mental health facilities and prisons. It's clear that there are lessons to be learned across the custodial network.

"Scottish Liberal Democrats have long campaigned to make our prisons humane and productive places by creating a properly funded justice system."

Mr McArthur added: "That means giving hard-pressed prison staff the resources they need, including a roll out mental health professionals across the estate.

"It also means ensuring that when deaths tragically occur, there is a swift and robust system in place to ensure they are properly investigated.

“On the SNP’s watch, overcrowding in Scotland’s prisons is at record levels and long-promised mental health support has gone largely undelivered.

"These failures have led to greater levels of violence, increased incidents of self-harm and a rising volatility that puts immense pressure on every aspect of the system."

Professor Armstrong said the cases are part of a "worrying pattern" that included reoccurring themes such as inappropriate care for people with drug issues, ignoring medical histories when assessing suicide risk and delays in medical treatment.

She added: "Of four suicides in prison investigated in FAIs, not a single one made identified any precautions, defects or made recommendations to prevent future deaths.”

Ms Barkas said a new human rights approach to investigating deaths in custody with meaningful involvement of families and loved ones should be considered.

She said: “The current system shows evidence of limited involvement and disregard of families with Sheriffs declining to explore discrepancies between official accounts and family evidence. "Families are often not represented in court or offered the chance to give evidence which leaves them feeling confused and alienated by the process.”

"Many investigations are concluded based entirely on written evidence agreed in advance by the Crown and the parties responsible for the care of the person who died.”

She added: "It is our belief that information about deaths in custody and how they are investigated should be more visible as a matter of public interest and state transparency in order to ensure these deaths no longer go unnoticed."